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Case 5
Congestive Cardiac Failure
Nephrotic Syndrome
Community-Acquired pneumonia

Siti Hasmah Bt Mohd Suffian


Name: MAMGender: Male
Age: 24 years old Race: Malay
Weight: 138 kgBMI: 55 (morbidly obese)
Height: 159cmDOA: 21st March 2010


Chief complaint:
bilateral lower limb swelling for the past 2 weeks.
scrotal swelling for the past 3 days but noted on DOA had progressively increased in size. •complained of vomiting for 5 days, vomits about 3-4 times per day •so far had vomited once in the afternoon and had 2 episodes of diarrhea on DOA

History of present illness:
had noted excoriation of the scrotal skin with some amount of clear fluid discharge •has been having difficulties in initiating micturation since morning of DOA •claimed that bladder habits were normal before this

history of occasional SOB for the past 2 weeks
orthopnea for 2 weeks
had reduced effort tolerance for the past 1 month
diarrhea for the past 3 days
has abdominal distension for the past 1 month
associated with abdominal discomfort and occasional bouts of vomiting •had seen the doctor and was treated for gastritis
had one episode of fever last friday
had epigastric pain since DOA
loss of appetite for the past 1 month
Had on and off cough for pass 2 months, whitish sputum

Family history:
father passed away due to esophageal cancer
mother has hypertension and diabetes mellitus

Social history:
smoker for the past 8 years (14 sticks per day) but quitted 2 months ago

Past medical and medication history:
Have been taking T. Piroxicam (Roxim) for his pain management •History of peptic ulcer 3 months ago

Review of system:
BP = 127/54 mmHg
PR = 115 bpm (regular good volume)
T = 37oC
Lab values on day of admission:
Patient’s valueNormal Values
Full blood countTWBC25.6x 109/L 4-11 x 109/L
Hb12.6 g/dL 14-17.5 g/dL
RBC5.03 x 106/L 4.5-6.5 x 106/L
Hct39.0 % 40-54 %
Platelet353 x 109/L 150-400 x 109/L
Renal profileBUN 12.5 mmol/L 1.8-8.3 mmol/L
Na 131.7 mmol/L 135-152 mmol/L
K 4.12 mmol/L 3.5-5.4 mmol/L
Cl 95.6 mmol/L 98-106 mmol/L
Scr 275 Umol/L 0-126 Umol/L
CrCl (using BSA)40.5 mL/min 97-137 mL/min
Coagulation profilePT 33.5 sec11-16 sec
APTT 36 sec23-40 sec
INR 3.16
Random blood sugar7.81 mmol/L 4.4-8 mmol/L
Albumin25 g/L 43-50 g/L

Ward Medications:

22/3IV Amoxicillin Clavulanate 1.2 g stat then OD
IV Azithromycin 500 mg stat then ODInfection/Community-acquired pneumonia 22/323/3IV Omeprazole 20 mg statEpigastric pain following Azithromycin administration 23/3
23/3IV Amoxicillin Clavulanate 1.2 g OD
IV Azithromycin 500 mg ODInfection/Community-acquired pneumonia 21/3
29/3IV Furosemide 40 mg stat then TDS
IV Furosemide 40 mg BD
IV Furosemide 80 mg TDS
IV Furosemide 40 mg TDSDehydration
Pulmonary hypertension
Nephritic syndrome
21/323/3IV Ranitidine 50 mg stat then TDSEpigastric pain
25/3T Meloxicam 7.5mg ODNSAID for joint pain
26/3Miconazole creamAntifungal for skin excoriation on scrotal skin 27/328/3SC Fondaparinux 2.5mg ODDVT prophylaxis

Full blood count:

TWBC (4-11 x 109/L)23.025.315.315.017.5
RBC (4.5-6.5 x 106/L)
Plt (150-400 x 109/L)374353386469440
Ht (40-54 %)41.439.041.442.244.4
Hb (14-17.5 g/dL)13.312.612.712.412.9

Renal profile:

BUN (1.8-8.3 mmol/L)4.512.513.
Cl (98-106 mmol/L)101.395.699.9101.099.596.2
Cr (0-126 Umol/L)138.0275.0197.0104.088-
K (3.5-5.4 mmol/L)3.904.123.983.673.973.80
Na (135-152 mmol/L)135.8131.7131.2136.2140.0131.1
Liver function test:

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